Given the OR’s unique medication requirements, providing strict oversight is a challenging task for pharmacy. Nevertheless, such oversight is essential for ensuring medication safety and security. Furthermore, because high-alert medications are commonly used in this environment, rigorous supervision is especially critical. 

Peninsula Regional Medical Center (PRMC), in Salisbury, Maryland, is the region’s largest tertiary care facility, with 363 acute care beds, 28 nursery beds, and 30 transitional care beds. Prior to 2010, the pharmacy operated under centralized distribution, employing manual anesthesia carts in the ORs, endoscopy unit, and MRI and cardiac catheterization laboratories. These carts could not store controlled medications, as they lacked the ability to track utilization by user; thus, controlled medication kits had to be filled and delivered separately to central ADCs in the anesthesia areas, where each provider would sign out their kits for the day. Unfortunately, this time-consuming method inspired little confidence that our medication auditing processes were TJC-compliant. In addition, the manual processes for inventory control and charge capture were proving inefficient. Dissatisfaction with workflow requirements, as well as security concerns, thus prompted a change to storing controlled drugs in ADCs in the OR and anesthesia work areas. However, this method also was less than ideal, as anesthesiologists complained about the lack of access to controlled substances within their immediate work area. 

Nursing’s low satisfaction with medication turnaround times from pharmacy was another concern that needed to be addressed. These combined factors drove our hospital to transition from a centralized to a point-of-care distribution model in 2010. As part of the overall plan to increase efficiency, automated anesthesia carts were purchased to improve medication security and enhance charge capture, as well as to ensure compliance with TJC’s medication security requirements. In September 2011, automated anesthesia carts were implemented in all of the hospital’s ORs and procedural areas, requiring several steps to plan and execute this large-scale implementation.

Evaluating Equipment Requirements
Our previous use of manual carts allowed us to estimate the quantity of automated carts required to meet our needs. After reviewing anesthesiology usage patterns both within and beyond the ORs, the decision was made to install one cart in each of our 18 ORs, one in the endoscopy unit, and also to purchase one flex cart, which travels from area to area as needed. The flex cart is typically utilized in the endoscopy unit during peak periods, and occasionally in the MRI unit; depending on the size of the hospital, one cart may need to be specifically dedicated to MRI. This configuration has proven effective at PRMC, although due to volume growth in endoscopy we have budgeted for two new cart installations in this unit within the next fiscal year. 

After surveying the various locations where the carts would be used, pharmacy and anesthesiology agreed upon each cart’s ideal location, which proved in every case to be the same location in which the manual cart had been located. Because additional equipment, such as anesthesia gas machines, may be installed in the future, it is important to plan carefully to avoid negatively impacting patient movement in and out of the ORs. We continue to use some ADCs in anesthesiology areas—two units in the core OR, one for the heart rooms, one for the eye rooms, and one for the endoscopy suite—although upon implementation of the automated anesthesia carts, they now house dramatically less inventory.

Determining where the carts should be placed should depend in part on whether the carts will be powered by a wired or wireless connection. Although our facility has a robust wireless network, initially we were concerned about connection stability and potential areas of noncoverage, so we opted for wired carts. In retrospect, this decision was unwise, as the wired connections introduced connectivity disruptions when machines were moved. Consequently, we are now in the process of converting all our anesthesia carts to wireless connections. When considering your product options, evaluate the technology capabilities at your hospital; purchasing carts with a wireless option is strongly recommended. 

Anesthesia Cart Access
During the implementation, determine who will have access to the carts and who will be authorized to perform double checks on wasted medications. At PRMC, all anesthesiologists and CRNAs can access the carts. To expedite workflow when wasting controlled medications, we chose to allow certain carefully selected OR nurses to serve as witnesses for wasting, as it is often difficult to locate another anesthesia provider to perform this function. 

Utilizing Anesthesia Cart Functionality
Work together with anesthesiology to determine which medications will be housed in the carts, their relative placement within the carts, and the quantity of medication and supply drawers that will be utilized. Early in the process we standardized content in all 20 carts, although later we modified the endovascular cart to be more specific to that area, and are considering modifying the carts in the cardiovascular ORs as well. Also, initially we determined that four drawers would be required to store medications, but upon implementation it became clear that only three drawers should hold medications, with one drawer reserved for supply storage. Thoroughly vetting the usefulness of each medication to be placed in the carts should prove highly beneficial. 

Collaborate for Success
The fruitful collaboration between pharmacy and anesthesiology led to a smooth implementation. Pharmacy sought anesthesiologists’ buy-in from the initial stages of the project and provided training in the correct use of the new technology, while delineating the patient safety and workflow benefits that would result from appropriate usage. Moreover, pharmacy is now confident that OR medication oversight is compliant with TJC requirements. Providing hands-on cart training and information about proper use, as well as highlighting the ways in which the technology would improve workflow, helped to ensure the project’s success.

Dennis Killian, PharmD, PhD, received his graduate degrees from the University of Maryland-Baltimore School of Pharmacy in 1999 and 2001, respectively. He currently serves as director of pharmacy services at Peninsula Regional Medical Center in Salisbury, Maryland, and also as an associate professor of pharmaceutical sciences at the University of Maryland Eastern Shore School of Pharmacy. 

Automated Anesthesia Cart Buyer’s Guide

MedSelect Anesthesia from AmerisourceBergen Technology Group (ABTG) provides pharmacists with the ability to electronically capture real-time tracking information of medication administration in the OR to eliminate additional chart auditing of billed versus administered doses. Proper credentials are required to access medications and narcotics are separately credentialed during a case, providing added security and tracking. The software provides real-time reconciliation and wasting of narcotics and medications for a complete electronic medication administration record.

The anesthesia cart is designed with the OR workflow in mind. Once a case is opened, users have easy access to the contents of the cart, eliminating time-consuming, manual processes. The software also assists with clinical decision support regarding allergies, drug interactions, and administration guidelines.

The bar coding and labeling system provides closed-loop narcotic tracking, accurate charge capture, and decision support at the point of care. The label, which is Joint Commission–compliant, is applied in the pharmacy and includes a tracking bar code on each dose. In the OR, the anesthesia provider tears off the breakaway label and applies it to the appropriate syringe before administration. 

The bar code can then be scanned at administration to accurately capture the charge for the correct case. The individualized bar codes also prevent syringe reuse and provide enhanced narcotic and inventory control. 

AmerisourceBergen 
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The Pyxis Anesthesia System from CareFusion is a secure, automated medication dispensing system enabling users to conveniently access, document, and audit OR medications, including controlled substances. By replacing manual carts and narcotic boxes, the system saves time and effort, resulting in improved medication availability, documentation, and enhanced security. It securely stores and electronically tracks medications used in the OR to help ensure medications are available and can be quickly accessed. 

By easily tracking and transferring medications from patient to patient, anesthesia providers can streamline documentation and the pharmacy can reduce medication returns, credits, and waste. Furthermore, the software supports personalized workflow for the anesthesia provider with options such as bar coding, kit selection, and a touch-screen virtual drawer that mirrors the actual drawer setup. 

The Pyxis Anesthesia System electronically tracks inventory and expiration dates, and supports verification of medication administration records, which can improve charge capture. Additionally, it facilitates regulatory compliance by securely storing controlled substances and accurately maintaining a dispensing database. The data from the system drives integrated analytics solutions that provide actionable information that facilities can use to unlock performance and help improve safety, such as a diversion watch list that identifies anomalous user activity, which may indicate diversion or improper use.

CareFusion
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Anesthesia-Rx from McKesson complements existing OR workflow, enabling easy adoption by providers. Simplified dispense and restock scanning workflows minimize screen interaction, providing fast and reliable access to medication, while improving inventory accuracy and charge capture. The RapiDispense feature allows users to remove a non-controlled substance from an open matrix drawer and scan the bar code to dispense. The cart automatically tracks medication inventory and reports dispense history.

Anesthesia-Rx can easily be moved to required locations, keeping medication close to the patient, while supporting next case and emergency preparation of medications in order to improve efficiency. The cart has a unique lockout prevention system that provides reliable access to medication, even in the event of an emergency when medication is needed immediately. The integrated color syringe label printer helps improve regulatory compliance and patient safety by automatically printing a color label with the required regulatory information, allowing for easy identification during procedures. 

Expiration date tracking provides the ability to remove expired medications from the cart, while real-time reporting enhances communication between the pharmacy and the OR. As medication is stocked, dispensed, returned, and wasted, the pharmacy is able to view reports in order to efficiently track inventory. Anesthesia-Rx is a Class 1 Medical Device and adheres to strict quality standards as defined by the FDA.  

McKesson
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